A resident at the Renaissance at 87th Street nursing home in Chicago, Illinois fell from his bed and broke two vertebrae. The fall was the second in six days for the resident, who was initially admitted to the nursing home with diagnoses of hypertension, atrial fibrillation, congestive heart failure, abdominal pain, muscle weakness and cancer.
Nursing home falls happen. Although most nursing home falls are predictable based on extensive screening and evaluation, there are times when a fall can truly be an accident. Two falls, both of which occurred while the resident was in his bed, makes the likelihood of their both being accidents extremely unlikely.
The incident report from Renaissance at 87th written after the first fall gives no indication that staff know why the fall happened. However, the plan of care dated just prior to the fall includes a note to “Maintain needed items within reach.” After the first fall, a note was added instructing staff members to “Give pain medication per resident’s request.”
It seems possible that the resident, whose list of ailments includes chronic pain and cancer, was desperately trying to secure pain medications when he fell. In an understaffed nursing home, the wait for staff to respond to a call light can seem endless to a resident in pain.
Even if the falls were caused by completely different reasons, Renaissance at 87th should have paperwork to document their investigation. However, when nursing home inspectors asked to see copies of the resident’s recent nursing home fall assessments, they were not able to produce them without significant delays.